Consultation Form 2021

Consultation Form 2021

Regarding any treatments with Beauty by Elsa
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Date of Birth

DayMonthYear
Medical History
Please list any allergies known
Have you ever had (Please check all that apply)*

AnemiaAsthmaArthritisCancerDiabetesEpilepsy SeizuresFainting SpellsHeart DiseaseHeart AttackHigh Blood PressureHepatitisSleep ApneaThyroid ProblemsOedema (water retention)PsoriasisSunburnMolesScar tissueUndiagnosed Lumps or BumpsPhlebitisVaricose VeinsSkin DiseasesHypersensitive skinNone of the above
Other illnesses:
Are you under any medications?

YesNo
If YES, Please list your Current Medications
Do you use any of these products?

Retin AGlycolic AcidAccutane or any Acne medications
Include other comments regarding your Medical History
Should be Empty:

Medical History